RESEARC H ARTIC LE Open Access Process evaluation of a participatory ergonomics programme to prevent low back pain and neck pain among workers Maurice T Driessen 1,2 , Karin I Proper 1,2 , Johannes R Anema 1,2* , Paulien M Bongers 1,2,3 , Allard J van der Beek 1,2 Abstract Background: Both low back pain (LBP) and neck pain (NP) are major occupational health problems. In the workplace, participatory ergonomics (PE) is frequently used on musculoskeletal disorders. However, evidence on the effectiveness of PE to prevent LBP and NP obtained from randomised controlled trials (RCTs) is scarce. This study evaluates the process of the Stay@Work participatory ergonomics programme, including the perceived implementation of the prioritised ergonomic measures. Methods: This cluster-RCT was conducted at the departments of four Dutch companies (a railway transportation company, an airline company, a steel company, and a university including its university medical hospital). Directly after the randomisation outcome, intervention departments formed a working group that followed the steps of PE during a six-hour working group meeting. Guided by an ergonomist, working groups identified and prioritised risk factors for LBP and NP, and composed and prioritised ergonomic measures. Within three months after the meeting, working groups had to implement the prioritised ergonomic measures at their department. Data on various process components (recruitment, reach, fidelity, satisfaction, and implementation components, i.e., dose delivered and dose received) were collected and analysed on two levels: department (i.e., working group members from intervention departments) and participant (i.e., workers from intervention departments). Results: A total of 19 intervention departments (n = 10 with mental workloads, n = 1 with a light physical workload, n = 4 departments with physical and mental workloads, and n = 4 with heavy physical workloads) were recruited for participation, and the reach among working group members who participated was high (87%). Fidelity and satisfaction towards the PE programme rated by the working group members was good (7.3 or higher). The same was found for the Stay@Work ergocoach training (7.5 or higher). In total, 66 ergonomic measures were prioritised by the working groups. Altogether, 34% of all prioritised ergonomic measures were perceived as implemented (dose delivered), while the workers at the intervention departments perceived 26% as implemented (dose received). Conclusions: PE can be a successful method to develop and to prioritise ergonomic measures to prevent LBP and NP. Despite the positive rating of the PE programme the implementation of the prioritised ergonomic measures was lower than expected. Trial registration: Current Controlled Trials ISRCTN27472278 * Correspondence: h.anema@vumc.nl 1 Body@Work TNO VUmc, Research Center Physical Activity, Work and Health, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands Full list of author information is available at the end of the article Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Implementation Science © 2010 Driessen et al; licensee BioMed Central Ltd. This is an Open Acce ss article distributed under the terms of the Creative Commons Attributio n License (http://creativecomm ons.org/licenses/by/2.0 ), which permi ts unrestricted use, distribution, and reproduction in any medium, provided the original work is pro perly cited. Background The prevalence of low back pain (LBP) and neck pain (NP) among workers is high [1,2]. To prevent or reduce these symptoms, ergonomic interventions are commonly applied [3]. However, ergonomic intervent ions appeared to be most often not eff ective in the prevention of LBP and NP [2,4-6]. An important reason for finding no effects on LBP and NP might be due to the inadequate implementation of ergonomic measures (i.e.,compli- ance, satisfactions and experiences) and the lack of using adequate implementation strategies [7]. Participatory ergonomics (PE) is a noted i mplementa- tion strategy to develop ergonomic measures from the bottom up [8-10]. According to the stepwise PE method, ergonomic measures are developed by working groups (consisting of workers, management, and other impor- tant stakeholders) [8,10-12]. By using this bottom up approach, the acceptance to use the ergonomic mea- sures may become more widespread among end-users (i.e., workers). To inform, educate, and instruct workers on the PE process, other supportive implementation strategies, such as distrib ution of brochures and flyers, providing training, and capitalising on opinion leaders are used [13,14]. The actual implementation of ergo- nomic measures is considered as a (possible) conse- quence of the PE process and can be enhanced by the use of additional implementation strategies (e.g.,useof opinion leaders). The effects of PE on the reduction of musculoskeletal disorders (MSD) have shown to be promising [15-21]. However, it sho uld be noted that most studies on the effectiveness of PE were of low quality and were con- ducted in a working population with heavy workloads. Studies directly assessing the prevention of MSD are rare, especially those using a r andomised study design. The only randomised controlled trial (RCT) in the area of PE and the prevention of MSD has been conducted by Haukka et al. (2008). They showed that PE was not effective to prevent MSD among kitchen workers [22]. More high-quality studies (R CTs) evaluating the effe c- tiveness of PE are needed. Therefore, “The Stay@Work study” currently investigates the effectiveness of a PE programme on the prevention of LBP and NP among a heterogeneous population of workers [23]. In the past years, the conduct of process evaluations alongside RCTs ha s been recomme nded, because the y can facilitate the interpretation of the findings [24]. For example, a process evaluation can shed light on whether the intervention was delivered as intended (i.e., compli- ance, adherence, satisfaction, and experiences) as well as the success and failures of the intervention programme [25-28]. Moreover, the information obtained from a pro- cess evaluation can be used to further improve the intervention [26,29], and to enable the transition of research evidence into occupational health practice [30]. Therefore, this study evaluated the process of the Stay@Work PE programme, including the perceived implementation of the prioritised ergonomic measures. Methods This process evaluation was performed alongside a RCT on the effectiveness of a PE programme on the preven- tion of LBP and NP among workers, called Stay@Work. The Medical Ethics Committee of the VU University Medical Center approved the study protocol. Detailed information o n the methods, randomisation procedure, and intervention can be found elsewhere [23]. The departments of four large Dutch companies (a railway transportation company, an airline company, a univer- sity including its university medical hospital, and a steel company) were invited to participate in the study. The higher management of all companies agreed with the financial and organisational consequences of the inter- vention. Based on their main workload, participating departments were classified into: mental, p hysical, mix mental/physical, or heavy physical departments [31]. Within each company, one rand omisation pair of t wo departments with c omparable workloads was randomly allocated to either the intervention group (Stay@Work PE programme) or the control group (no Stay@Work PE programme). All workers at the departments of both groups received the baseline questionnaire and watched three short (45 seconds) educativemoviesaboutthepreven- tion of LBP and NP. The Stay@Work PE programme In short, the interv ention comprised a six-hour working group meeting, in which the steps of the Stay@Work PE programme were followed. Each intervention depart- menthadtoforma‘working group’, in which both workers and management participated as members [8,11]. Each working group consisted of at least one manager with decision authority, a maximum of eight workers who were a solid representation of the largest and most important task groups at the department. If available, an occupational health and safety coordinator was incorporated in the working group as well. Working group members had to have worked at least two years in their current job, wo rked for more than 20 hours per week at the department, had responsibilities within his/ her own task group, was a role model for his/her co- workers, and was motivated to participate as a m ember in the working group [23]. During the first meeting, the working group discussed a document containing infor- mation on risk factors on LBP and NP present at the Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 2 of 11 department, which were obtained from the ergonomist workplace visit (which was mandatory for each interven- tion department), pictures made by the working group members, and baseline questionnaire information (step one). Then, the working group could add other risk fac- tors of LBP and NP, and judged all mentioned risk fac- tors as to their frequency and severity. Based on the perceptions of the working group, the most frequent and severe risk factors were prioritised, resulting in a top three of risk factors (step two). Subsequently, the working group held a brainstorming session about dif- ferent types of ergonomic measures targeting the priori- tised risk factors, evaluated the ergonomic measures according to a criteria list considering: relative advan- tage, c osts, compatibility, complexity, visibility, and fea- sibility within a time frame of three months [32]. On a consensus basis, the working group prioritised the three most appropriate ergonomic measures (step t hree). Finally, the prioritised risk factors and the prioritised ergonomicmeasureswerewrittendowninanimple- mentation plan (step four). The implementation plan described for each ergonomic measure which working group members were responsible for its implementation. Based on their interests in the projects, the prioritised ergonomic measures were divided among the members of the working group. Working group members who had a responsibility towards implementation of a priori - tised ergonomic measure were called the ‘implementers.’ Attheendofthemeeting,theworkinggroupwas requested to implement the ergonomic measures (step five) a nd was asked whether an appo intment for a sec- ond, optional, meeting was necessary to evaluate or adjust the implementat ion process (step six). During the implementation process, all working groups were allowed to ask help from other professionals (i.e., techni- cians, engineers, or suppliers) or services (i.e., equipment or health services). To improve the implementation pro- cess, two or three working group members from each working group were asked to voluntarily follow a train- ing programme to become a Stay@Work ergocoach. In this additional four-hour implementation facilitation training, workers were e ducated in different implemen- tation strategies to inform, motivate, and instruct co- workers about the prioritised ergonomic measures. Moreover, the ergocoaches were equipped with a Stay@- Work toolkit consis ting of flyers, posters, and presenta- tion formats about the prioritised ergonomic measures. According to the Attitude - Social influence - self- Efficacy (ASE) behavioural change model that was applied during the PE programme, dissemination of information about ergonomic measures may increase worker’s self-awareness of their own beha viour and increase knowledge about possible ergonomic solutions. Thus informing workers can be regarded as a first step in order to induce a behavioural change [13,33]. The process evaluation An adapted version of the Linnan and Steckler frame- work, which has been recommended to be a useful guide for the conduct of a process evaluation, was used [34,35]. Table 1 presents the components that were addressed; recruitment, reach, fidelity, satisfaction, and implementation components (i.e., dose delivered and dose received). Table 1 Process evaluation components and their definitions Component Definition Recruitment - Number of intervention departments that agreed to participate - Number of working groups formed - Number of working group members recruited for additional ergocoach training - Number of workers who responded to the baseline questionnaire Reach - Number of worksite visits by ergonomist - Number of working group members who attended working group meeting - Number of working group members who attended the Stay@Work ergocoach training Fidelity - The extent to which the steps of the PE programme were delivered as intended Satisfaction - Satisfaction of working group members towards the prioritised risk factors and ergonomic measures, the ergonomist’s competences, and duration of the working group meeting - Satisfaction of working group members who followed the Stay@Work ergocoach training towards the course leader’s competences, and the duration of the training - Satisfaction of workers at the department towards the perceived implemented ergonomic measures and towards the intervention method (PE) that was used to develop the ergonomic measures Dose delivered - Perceived implementation of the ergonomic measures according to the implementers Dose received - Perceived implementation of the prioritised ergonomic measures according to the workers at the departments - Workplace implementation of the prioritised ergonomic measures according to the workers at the departments Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 3 of 11 Data collection The process evaluation was conducted for the interven- tion departments only. The PE programme is a complex intervention, containing components that may affect dif- ferent levels. Therefore, if appropriate, data on the com- ponents were c ollected on two levels (see Ta ble 2): department level (i.e., working group members from intervention departments) and participant level (i.e., workers from intervention departments). Recruitment Department level recruitment The department level was defined as the number of intervention depa rtments that agreed to participate in the study and the number of working gro ups formed. Managers who formed the working group had t o send a list with names of the working group members to the principal researcher. At the end of each working group meeting, two or three members were recruited for the additional Stay@Work ergocoach training. Participant level recruitment The level of the participant was defined as the n umber of workers who filled out the baseline questionnaire. Department level reach At the level of the department, ‘reach ’ was defined in two ways. First as the number of worksite visits con- ducted by the ergonomists. During a worksite visit, the ergonomist observed activities or situat ions that were considered relevant for LBP and NP. Information on the workplace visits was sent to the principal researcher. Second, reach was defined as the number of workers that attended the working group meeting and the num- ber of working group members that attended the Stay@- Work ergocoach training. Before the start of each session, all working group members had to sign a list to confirm their attendance . Reasons for not attending were registered. Department level fidelity and satisfaction Directly after finishing the working group meeting, all working group members were asked to report on the components fidelity and satisfaction: at the level of the department, ‘fidelity’ was defined as the extent to which the steps of the PE programme were delivered as intended, and was rated on an 1-10 point scale (very bad to very good); at the level of the department, ‘satis- faction’ was rated on an 1-10 point scale (very unsatis- fied to very satisfie d) and encompassed satisfaction towards the outcomes (risk factors and ergonomic mea- sures prioritised), the ergonomist’scompetences,and the duration of the meeting was assessed. By using the same components ( fidelity and satisfaction) and mea- sures (1-10 scale), the Stay@Work ergocoach training was evaluated. Participant level satisfaction At the level of the participant, satisfaction could only be measured among workers who perceived at least one ergonomic measure as implemented. By using an 1-10 point scale (very unsatisfied to very satisfied), satisfac- tion with the perceived implemented ergonomic mea- sure(s) w as assessed; likewise, satisfaction with the intervention method (PE) used to develop ergonomic measures was measured. These workers were also asked on how they took notice of the supportive implementa- tion measures (i.e., e-mail/poster/flyer). Implementation Department level dose delivered Four months after finishing the working group meeting, the implementers – working group member(s ) responsi- ble for the implementation of one or more prioritised ergonomic measure(s) – received a short questionnaire. Implementers were asked w hether the prioritised ergo- nomic measures for which he/she was responsible for were realised (implemented) at the dep artment as Table 2 Process evaluation data collection: main levels and methods Component Department level Participant level Data collection tool Recruitment X X Checklist and baseline questionnaire Reach X Checklist Fidelity X 1 to 10 scale (very bad to very good) Satisfaction X X 1 to 10 scale (very unsatisfied to very satisfied) Dose delivered X Questionnaire assessing for each prioritised ergonomic measure the perceived implementation (yes/partly/no) Dose received X Questionnaire assessing for each prioritised ergonomic measure the: 1) Perceived implementation (yes/no/don’t know) 2) Workplace implementation (yes/no) Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 4 of 11 describ ed in the original implementation plan. The per- ceived implementa tion was assessed separately for each ergonomic measure. For each ergonomic measure, the implementers could choose from three answer categories: 1. yes, implemented: the prioritised ergonomic mea- sure was realised as described in the implementation plan. 2. yes, partly implemented. 3. no, not implemented: the prioritised ergonomic measure was not realised as described in the implemen - tation plan. This method enabled the investigators to calculate for each ergonomic measure of interest a percentage of the perceived implementation. The implementation per cen- tage was de rived by summing the frequencies of each of the three answer categories (yes, implemented/yes, partly implemented/no, not implemented). By summing all implementation percentages and dividing by the total number of prioritised ergonomic measures, an overall implementation percen tage for all department s could be calculated. Participant level dose received All information on the participant level was obtained from workers w ho responded to the six-month follow- up questionnaire, and addressed information on: 1. The perceived implementation of the ergonomic measures was measured by means of a separate question that asked workers whether the prioritised ergonomic measure was imple mented by the working group at their department. F or each ergonomic measure, three answers were possible: yes/no/don’tknow.Byusinga procedure similar to the one for dose delivered, an over- all perceived implementation percentage was calculated. 2. The workplace implementation was assessed among those workers who perceived an ergonomic measure as implemented. By means of another question they were asked whether the ergonomic measure was applicable to their workplace (yes/no). The percentage of implemen- ted measures at their workplace was derived by dividing the number of ‘yes actually implemented’ by the number of ‘yes perceived as implemented’. Results Recruitment and reach Department level In total, 37 departments were included in the randomi- sation procedure with 19 departments randomised to the intervention group. Among the intervention depart- ments, 10 departments were characterised by mental workloads, one department had a light physical work- load, four departments had mixed workloads (physical and mental), and four departments had heavy physical workloads. One department with a mixed workload (n = 103 workers) dropped out of the study due to a sudden reor- ganisation, and no working group was formed at that department. Further, as the department managers of four departments with a ‘ment al workload’ were not able to select a sufficient number of workers to partici- pate in the working group, it was decided to form two working groups instead of four. Thus, out of 18 depart- ments, 16 working groups were formed. In total, 113 working group members were invited to participate. All working groups h eld a working group meeting, which was attended by 98 working group members (87%). Of the 15 non-attending members six were on sick leave, seven were too busy, one had a regular day off, and one was no longer working at the department. Eight Stay@Work ergocoach training sessions were held and were attended by 40 working group members. The number of members per working group that fol- lowed the training varied from one to six. Participant level The baseline questionnaire was sent to 5,695 workers, of whom 3,232 (57%) responded. A total of 185 workers did not meet the inclusion criteria for data analyses, which were: aged between 18 years and 65 years; no cumulative sick leave period longer than four we eks due to LBP or NP i n the past three m onths before t he start of the intervention; and not pregnant [23]. Hence, at baseline 3,047 (53%) workers were included. Among them, 1,472 workers were working at intervention departments. Complianc e to watching the movies on LBP and NP prevention in the intervention group was 67%. Fidelity and satisfaction Department level Six trained ergonomists conducted the worksite visits (n = 18) and guided the wo rking group meet ings. The number of working groups that each ergonomist guided varied from one to five. All 16 working groups completed the first working group meeting according to the study protocol and developed an implementation plan. Three working groups, all characterised by heavy physical workloads, planned the second (optional) working group meeting. Working group members (n = 98) rated the quality of the PE steps performed between 7.32 (SD 1.02) and 7.59 (SD0.99),andweresatisfiedwiththeriskfactorsand ergonomic measures prioritised (7.30, SD 1.15), the ergonomist’s competences (7.70, SD 0.92) a nd the six- hour duration of the meeting (7.06, SD 1.30). In total, 40 working group members (25 men and 15 women) followed the Stay@Work ergoc oach training and were positive about the quality of the training (7.67, SD 0.48), were satisfied with the course leader’s Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 5 of 11 competences (8.03, SD 0.70), and with the four-hour duration of the training (7.53 (SD 1.15)). Participant level Workers at the departments who perceived at least one of the ergonomic measures as implemented were informed about the ergonomic measure(s) by poster/ flyer/e-mail (55%), by a presentation provided by a working group member (41%), or by t heir supervisor (24%). Workers rated their satisfaction towards the ergo- nomic measures as prioritised by the working group (5.72, SD 2.39) and the method (PE) used to develop and prioritise the ergonomic measures (5.59, SD 2.29). In case the ergonomic measures we re implemented at their workplace, satisfaction towards the ergonomic measures was 6.02 (SD 2.31). Fo r the method used to develop and prioritise the ergonomic measures their satisfaction was 5.82 (SD 2.23). Implementation Department level: dose delivered In total, the working groups prioritised 66 ergonomic measures. The number of ergonomic measures per working group varied from three to six. The 66 priori- tised ergonomic measures were classified by two researchers independently from each other into t hree cat ego ries: individual, physical, and organisational ergo- nomic measures [36]. The classification resulted in: 32 individual, 27 physical, and 7 organisational ergonomic measures (see Table 3). To investigate whether the 66 prioritised ergonomic measures were actually implemented at the departments, the 81 implementers were sent a short questionnaire. A total of 65 of the implementers responded (80%). From the questionnaire, it appeared that the implementation status of three prioritised ergonomic measures was unknown (n = 1 individual, n = 2 physical). Therefore, this study evaluated the perceived implementation of 63 prioritised ergonomic measures (n = 31 i ndividual; n = 25 physical; n = 7 organisational). Implementers reported that altogether 34% of the prioritised ergonomic measures was implemented, 26% was partly implemented, and 40% was not implemented at the 18 departments. From the answers on the ques- tionnaire, it was shown that within working groups implementers sometimes disagreed on the implementa- tion status of the prioritised ergonomic measure. That is, one implementer perceived the measure as imple- mented, whereas another implementer within the same working group perceived the measure as not implemen- ted. Table 4 presents the percentages of the perceived implementation stratified by type of ergonomic measure and department workload. In general, highest imple- mentation rates were found for individual ergonomic measures (53%), and lo west implementation rates for organisational ergonomic measures (28%). At the light physical workload department, the implementation was 100%, but these results were obtained from only one department. Organisational ergonomic measures were most common at the departments with a mental work- load and were in most cases ‘partly’ implemented (47%). Departments with a heavy physical workload most often prioritised physical ergonomic measures (n = 12), but the perceived implementation was low (16%). Depart- ments with a mixed workload, and departments with a mental workload, most often prioritised individual ergo- nomic measures (n = 11). The perceived implementation between these two d epartment types, however, var ied largely (26% to 79%). Participant level: dose received According to the 833 wo rkers who responded to the per- ceived implementation questions in the six-month fol- low-up questionnaire, 26% perceived the ergonomic measures as implemented, 36% as partly implemented, and 38% as not implemented at the departments. Table 5 Table 3 Types and targets of the prioritised ergonomic measures (n = 66) Type of ergonomic measure Target of ergonomic measure N Individual (n = 32) Improving awareness regarding ergonomics 21 Worksite visits by an expert 2 Physical activity programmes 5 Training in working techniques, (i.e., lifting technique) 3 Personal protective equipment (i.e., kneepads) 1 Physical (n = 27) Ergonomic redesign and/or workstation modifications 18 Manual handling aids (i.e., lifting devices) 5 Equipment and/or tools 4 Organisational (n = 7) Installation of pause software 2 Develop protocol to improve worker’s health 1 Restructuring management style 2 Job rotation 2 Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 6 of 11 Table 4 Perceived implementation of the prioritised ergonomic measures according to the implementers (n = 65) Ergonomic measures perceived as implemented Type of ergonomic measure All departments (n = 18) Individual (n = 31) Physical (n = 25) Organisational (n = 7) Yes (%) 53 30 25 Partly (%) 21 26 47 No (%) 26 44 28 Mental workload departments (n = 10) Individual (n = 11) Physical (n = 7) Organisational (n = 5) Yes (%) 26 33 15 Partly (%) 32 41 46 No (%) 42 26 39 Light physical workload departments (n = 1) Individual (n = 1) Physical (n = 2) Organisational (N/A) Yes (%) 100 100 N/A Partly (%) 0 0 N/A No (%) 0 0 N/A Mixed workload departments (n = 3) Individual (n = 11) Physical (n = 4) Organisational (N/A) Yes (%) 79 31 N/A Partly (%) 17 13 N/A No (%) 4 56 N/A Heavy physical workload departments (n = 4) Individual (n = 8) Physical (n = 12) Organisational (n = 2) Yes (%) 44 16 50 Partly (%) 18 26 50 No (%) 38 58 0 N/A = not applicable Table 5 Perceived implementation of the prioritised ergonomic measures according to the workers at the departments (n = 833) Ergonomic measures perceived as implemented Type of ergonomic measure All departments (n = 18) Individual (n = 31) Physical (n = 25) Organisational (n = 7) Yes (%) 28 26 19 No (%) 37 38 38 Don’t know (%) 35 36 43 Mental workload departments (n = 10) Individual (n = 11) Physical (n = 7) Organisational (n = 5) Yes (%) 21 30 18 No (%) 44 42 52 Don’t know (%) 35 28 30 Light physical workload departments (n = 1) Individual (n = 1) Physical (n = 2) Organisational (N/A) Yes (%) 40 32 N/A No (%) 32 44 N/A Don’t know (%) 28 24 N/A Mixed workload departments (n = 3) Individual (n = 11) Physical (n = 4) Organisational (N/A) Yes (%) 31 36 N/A No (%) 36 37 N/A Don’t know (%) 33 27 N/A Heavy physical workload departments (n = 4) Individual (n = 8) Physical (n = 12) Organisational (n = 2) Yes (%) 35 20 20 No (%) 29 36 67 Don’t know (%) 36 44 13 N/A = not applicable Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 7 of 11 presents the percentages of the perceived implementation of the ergonomic measures stratified by type of ergo- nomic measure and department workload. Among the 26% of the workers who perceived the ergonomic mea- sures as implemented at the departments, the ergonomic measure was in 69% of the cases implemented at their workplace. Discussion The Stay@Work study investiga ted whether PE is an effective method to prevent LBP and NP among work- ers. The aim of the current study w as to evaluate the process of the Stay@Work PE programme implementa- tion including the perceived implementation effective- ness of the prioritised ergonomic measures. The results of this process evaluation showed that almost all department managers formed a working group and that a meeting was held with all working groups. Attendance rates of the working group meetings were good, and all working groups were successful in developing an implementation plan with prioritised risk factors for LBP and NP and prioritised ergonomic mea- sures to prevent LBP and NP. Working group members were positive about the quality of the PE steps per- formed during the meeting, meeting duration, and the prioritised ergonomic measures. These opinions were not shared among the remaining workers at the depart- ments. Attendance rates of the Stay@Work ergocoach training and the quality of t he training were good. Workers at the departments were no t satisfied with the implementation strategy used. Dissatisfaction may have occurred because workers at the departmen ts were kept blind as to the study design and were thereby only mar- ginally informed a bout the PE programme content and its aims. It is plausible that workers at the d epartments did not link the prioritised ergonomic measures to the PE programme and were therefore not sufficiently able to rate their satisfaction with the used method. More- over, dissatisfaction among workers might have occurred because they were asked to report on the implementa- tion of ergonomic measures that were not (always) applicable to their workplace. However, workers’ satis- faction towards both the prioritised ergonomic measure and the method that was used to develop the ergonomic measures increased somewhat when the ergonomic measures were implemented at their workplace. Overall, it can be concluded that the Stay@Work PE programme is a successful and feasible strategy to develop an implementation plan with prioritised risk factors for LBP and NP and prioritised ergonomic mea- sures t o prevent LBP and NP. It is more difficult, how- ever, to draw conclusions regarding the implementation ratesasthereisnocut-offpoint to determine whether implementation was successful or has failed. Regarding the prevention of LBP and NP it can be suggested that every (extra) ergonomic measure implemented might be profitable [3,37,38], even when perceived implementa- tion rates of 34% a nd 26% are derived. Future r esea rch should investigate whether the implementation rates found in this study are sufficient to reduce workload and thereby reduce LBP and NP prevalence among workers. The perceived implementation rates found in our study differed from other studies on PE. For example Haukka et al. (2008) conducted a RCT on PE and MSD prevention and reported a perceived implementation rate of 80% (402 ergonomic changes) [22,39], although it remained unclear how they assessed whether an ergo- nomic measure was implemented. There are several explanations for the different implementation rates found in our study compared to other PE studies like the Haukka study. In our study, individual ergonomic measures were prioritised most often, especially among departments with a mixed workload. The choice to prioritise and implement individual ergonomic measures seemed plau- sible, since the ergonomic measures were evaluated according to a set of common implementation criteria: low initial costs, not complex, compatible, visible, and feasible within three months. In line with other studies on PE, physical ergonomic measures were also priori- tised frequently. However, other studies also found higher frequencies on organisational ergonomic mea- sures [16,17,22,39,40]. The reason why fewer organisa- tional ergonomic measures were prioritised in this study may be a result of the implementation criteria that were probably less app licable to evaluate organisati onal ergo- nomic measures. In addition, the implementation of physical or organisational measures is more complex, expensive, and time consuming to perform compared to individual ergonomic measures [30]. Another possible explanation involves the inconsistent answers on the implementation status of the prioritised ergonomic measure (yes/no/partly implemented). For example, within the same working group, two out of the five implementers reported that the prioritise d ergo- nomic measure was implemented, whereas t he remain- ing implementers reported that the ergonomic measure was n ot implemented. Such inconsistencies often made it impossible for the researchers to decide whether a measure really was implemented. More knowledge about the implementers’ reasons for choosing a certain implementation status may have helped the researchers to make decisions about the implementation status of the prioritised ergonomic measures. However, due to the purpose of this study, no information on such rea- sons was colle cted. Furthermore, inconsistency may have been caused by the high number of ‘ yes, partly Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 8 of 11 implemented’ answers. In our questionnaire that was sent to the implementers, we did not specifically define the term ‘yes, partly implemented’. However, from the information obtained from the questionnaire we suspect that some implementers chose ‘yes, partly implemented’ when they discovered that it was more beneficial to implement a prioritised ergonomic measure for only a subgroup of workers rather than for all workers at the intervention department. Other implementers appear to have chosen ‘yes, partly implemented’ when the imple- mentation of the prioritised ergonomic measure was in progress but had not been completely realised yet. For example, in case of the implementation of a lifting device, implementers ordered the device; however, the lifting device was not yet being used at the workplace. Finally, although several explanations for the modest implementation have been discussed, it is possib le that other unmeasured factors might have occurred during the implementation period (e.g., hierarchy, poor manage- ment support, lack of assistance, o r financial problems) thereby hampering implementation [41]. For example, it is plausible that a lack of financial resources may have hampered the implementation of ergonomic measures. This is because most working groups were conducted in 2008 – a t ime when many Dutch companies experi- enced the consequences of the international financial downturn. Moreover, different implementation factors may be p resent or absent at different stakeholder levels (i.e., individual professional, worker, societal, or organi- sational level) [14]. More in-depth knowledge on imple- mentation factors and their stakeholder level can help researchers to improve ergonomic interventions. There- fore, to further improve the implementation of this or future PE programme(s), it may be helpful to explore what factors hampered or facilitated the implementation of ergonomic measures. Strengths and weaknesses of the process evaluation No other s tudy implemented PE on such a large scale and among departments with different type of work- loads. Furthermore, this process evaluation study col- lected extensive data on the perceived implementation. In doing so, this study attempted to estimate the effi- ciency of the PE programme and t he implementation strategies. The existing literature suggests that the use of informational material alone is not sufficient to induce a behavioural change (i.e., use of ergonomic mea- sures). More active strategies such as toolkits a nd local opinion leaders should be used to disseminate informa- tion [13]. Therefore, a strength of this study was that not only informational materials but a lso ergocoaches (opinion leaders) trained to inform, motivate, and instruct their c o-workers on t he ergonomic mea sures. Further, data were collected from different stakeholders at different levels which provided a better understanding of how the different stakeholders experienced the PE programme and the implementation strategies. A weakness of this study is that selection bias may have occurred because not all implementers and not all work- ers at the department responded to their questionnaires. Furthermore, the accuracy of the method that was used to measure implementation is debatable. All workers at the department were aske d whether the prio ritised ergo- nomic measures were implemented. Due to the variety of task groups within departments, it may be that some workers were asked to report on implementations that were not meant for their workplace. The same goes for the implementers, who d uring the implementation of the ergonomic measures may have discovered that a priori- tised ergonomic measure was more beneficial for a sub- group of workers rather than for the whole department. This may have led to misinterpretations of the concept of implementation and may have resulted in inconsistent answers on the questionnaires. A possible solution to overcome such inconsistencies and to increase the valid- ity of the answers provided by the implementers is to arrange control visits by an ergonomist [42]. Finally, the role of the ergonomist in the current study was restricted to guiding t he working group meeting. In line with the PE literature [43], working group members themselves were responsible for the implementation of the priori- tised ergonomic measures. Although working group members were allowed to seek help from other profes- sionals during the implementation period, no informa- tion on which professionals were consulted was collected. It is, however, plausible that more assistance and cooperation from the ergonomist, other professionals (i.e., suppliers, technicians, and purchase) and the man- agement to realise implementation, might indeed have led to higher implementation rates. Summary The results of this process evaluation showed that PE can be a feasible and successful strategy to develop an implementation plan with prioritised risk factors for LBP and NP and prioritised ergonomic measures to pre- vent LBP and NP. Moreover, recruitment, reach, fidelity, and satisfaction towards the PE programme were good. The same was found for the Stay@Work ergocoach training. Despite the positive rating o f the PE pro- gramme and the ergocoa ch training, the implementation of the prioritised ergonomic measures was lower than expected . Further research is needed to develop and test ways to more optimally implement PE programmes in order to reduce work-related injuries and to promote worker well-being. Driessen et al. Implementation Science 2010, 5:65 http://www.implementationscience.com/content/5/1/65 Page 9 of 11 Acknowledgements This study is granted by: The Netherlands Organisation for Health Research and Development (ZonMw). Author details 1 Body@Work TNO VUmc, Research Center Physical Activity, Work and Health, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. 2 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. 3 TNO Quality of Life, Polarisavenue 151, 2132 JJ, Hoofddorp, The Netherlands. Authors’ contributions All authors contributed to the design of the study. 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Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit . RESEARC H ARTIC LE Open Access Process evaluation of a participatory ergonomics programme to prevent low back pain and neck pain among workers Maurice T Driessen 1,2 , Karin I Proper 1,2 , Johannes. Driessen et al.: Process evaluation of a participatory ergonomics programme to prevent low back pain and neck pain among workers. Implementation Science 2010 5:65. Submit your next manuscript to BioMed. MT, Anema JR, Proper KI, Bongers PM, van der Beek AJ: Stay@Work: Participatory Ergonomics to prevent low back and neck pain among workers: design of a randomised controlled trial to evaluate the